What is Reimbursement in Health Insurance?

Reimbursement health insurance is a type of insurance policy where the policyholder pays for the medical expenses upfront and then claims reimbursement from the insurer. This form of insurance offers flexibility as you can choose any hospital for treatment without being restricted to a network. It is crucial to understand how this process works, especially during medical emergencies, to avoid unnecessary hassles. In a reimbursement claim, the policyholder makes the payment and then raises the claim. If the claim is approved, the insurer makes the required reimbursement accordingly. In a cashless claim, the claim is made during the hospitalisation and the payment is made directly by the insurer to the network hospital. In this article, we will explore the reimbursement claim process, its types, inclusions, and the documents required to ensure a smooth claim experience with your health insurance provider, like Bajaj Allianz General Insurance Company.

How does Reimbursement Health Insurance Work?*

To understand how reimbursement health insurance works and differs from its counterpart, let us see how it works.

1. Once you buy the reimbursement health insurance plan, you are covered under it as per its terms and conditions.
2. In the case of a medical emergency, you can seek medical treatment at any hospital of your choice.
3. The treatment expenses would have to be borne by you for the moment. You must keep all the bills, receipts and records safely with you.
4. Once you are able to, you must submit a claim to the insurance company for the medical expenses (if they are covered within the health insurance plan) within the stipulated time.
5. For the claim, you must fill out the relevant form and submit the necessary documents (bills and other medical records) to the insurance company.
6. Once submitted, the claim documents will be verified by the insurer. In case of any additional assistance, they may reach out to you.
7. If the claim is approved, you will receive the payment (i.e., the reimbursement) for the medical expenses, in accordance with the policy’s terms and conditions.

Apart from reimbursement and cashless claims, some general insurance plans, such as critical illness insurance, have a benefit-based claim process. Here, the insurer makes a pre-defined pay-out (after which the policy may cease to operate) if the insured person is diagnosed with a particular illness or has to undergo surgery. These are called defined-benefit health insurance plans.

Types of Reimbursement Claims in Insurance Claim

There are mainly two types of reimbursement claims: healthcare reimbursement and cashless claims. Let’s take a closer look at them:

1. Healthcare Reimbursement

This traditional type of claim involves paying for the medical expenses out-of-pocket and then submitting a reimbursement form to the insurance company along with all the required documents. Once the claim is verified and approved, the insurer reimburses the expenses as per the policy terms. Advantages:

• Flexibility to choose any hospital.
• Personalised healthcare decisions.
• Less dependency on network hospitals.

Limitations:

• Out-of-pocket expenses have to be borne initially.
• Requires proper documentation and adherence to claim submission deadlines.

2. Cashless Claims

This type of claim is processed directly between the hospital and the insurer. The policyholder does not have to pay for the treatment, as the insurance company settles the bill directly with the hospital, provided it is a part of the insurer’s network. Advantages:

• No upfront payment required.
• Hassle-free treatment during emergencies.

Limitations:

• Limited to network hospitals.
• Pre-authorisation is required before treatment.

Features and Benefits of Reimbursement Health Insurance 

Now that you know how reimbursement health insurance works, let’s understand how it may benefit policyholders.

You can choose any hospital you want

Unlike cashless health insurance where you are bound to a pre-approved list of hospitals, you can choose any hospital for treatment with reimbursement health insurance. This way, you choose a hospital where you believe you may get the right treatment.

Claim can be raised post-treatment

One of the benefits of reimbursement health insurance is that one can apply for a claim after their medical treatment is complete and the bills are settled. This ensures that you do not have to worry about any administrative problems during your treatment. Instead, you can focus on rest and recovery.

Personalised healthcare choices

Your health is personal, and so should your healthcare choices. Reimbursement health insurance allows you to make your medical decisions based on your preferences and requirements. This ensures that your health insurance aligns with your unique needs, which can encourage a stronger sense of control over your well-being. Claims are subject to terms and conditions set forth under health insurance policy.

Things You Should Consider Before Opting for Health Insurance Reimbursement Claims

Every general insurance claim is carried out via a specific procedure. When it comes to reimbursement health insurance, these are some things you should know:

Know what is covered

You must thoroughly review your policy to make sure that the expenses you are opting for are covered under the plan. Raising a claim for a medical issue which may be excluded may lead to a waste of time and energy.

Maintain all medical records

Remember to keep all receipts and documents related to the medical treatment for future reference safely.

Know claim time limits

When it comes to raising a claim, every insurer has a time limit. Hence, be mindful of claim time limits to ensure that you submit everything on time.

Be aware of the sub-limits

A sub-limit refers to a limitation on a particular expense related to medical treatment. For instance, some health insurance plans have a room rent sub-limit; medical expenses under ‘room rent’ shall be reimbursed only till a particular amount or a percentage of the total amount.

Know that cashless options are available

All health insurance plans are likely to have a cashless feature. So, if you are unable to pay large amounts of cash upfront for treatment, you can consider cashless health insurance as well. Claims are subject to terms and conditions set forth under health insurance policy. Before you opt for reimbursement health insurance, you should get an idea of its premium. For that purpose, you can use a health insurance calculator. Read More: Things To Consider Before Buying A Critical Illness Policy

Documents Required for Reimbursement Claim

1. Duly filled reimbursement form
2. Original bills and receipts
3. Discharge summary
4. Doctor’s prescription
5. Diagnostic test reports
6. Policy details

How to Raise a Reimbursement of Medical Expenses

Raising a reimbursement claim involves a few steps that need to be followed meticulously to ensure a smooth process:

1. Collect All Documents: Gather all the bills, medical reports, and prescriptions related to your treatment.
2. Fill the Reimbursement Form: Download and fill out the insurer’s reimbursement form accurately, ensuring all necessary details are included.
3. Submit to the Insurer: Attach the form and documents, and submit them to the insurer within the stipulated time frame.
4. Verification and Approval: The insurer will verify the documents. If everything is in order, the claim will be approved and the amount reimbursed.

Inclusions in a Mediclaim Reimbursement Claim

A typical reimbursement health insurance policy covers various expenses such as hospitalisation costs, pre and post-hospitalisation expenses, diagnostic tests, surgeries, and doctor’s fees. However, it is crucial to check your policy document for specific inclusions and exclusions to avoid any surprises during claim settlement.

Conclusion

In conclusion, while reimbursement health insurance may require more administrative effort, it provides flexibility and control over your healthcare decisions. It is important to review the policy carefully, maintain proper documentation, and raise the claim within the stipulated time to ensure a seamless claim experience. Read More: Health Insurance Claim Settlement Ratio: A Complete Guide

FAQs

How long does it typically take for a reimbursement claim to be processed?

The time for processing a reimbursement claim can vary depending on the insurer. Typically, it takes around 15-30 days from the submission of all required documents.

Are there any waiting periods for specific treatments or conditions in my policy?

Yes, most policies have a waiting period for certain treatments or pre-existing conditions. Check your policy document for detailed information.

How can I ensure my expenses fall within the maximum limit set by my policy?

Keep a track of your expenses during treatment and compare them with the sub-limits set by your policy. Always check the coverage for room rent, doctor’s fees, and other medical costs.

What expenses can be reimbursed?

Expenses such as hospitalisation costs, diagnostic tests, surgeries, and post-hospitalization treatments are generally covered. Refer to your policy for detailed inclusions. *Standard T&C apply. Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making any related decisions. Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.